ICU Resource Allocation Framework

7.1 The Welsh Government recognises the importance of having clear ethical and operational principles to guide decision‑making in the extreme situation that adult intensive care services become saturated during a pandemic. Any framework would need to support clinicians, protect patients’ rights, promote fair and consistent decisions and maintain public confidence. 7.2 At the start of the Covid‑19 pandemic, the NHS in Wales used the 2017 All‑Wales Critical Care Escalation Guidance. This guidance, set out how intensive care units should respond to increasing pressure. However, it did not set out how decisions should be made if demand became greater than the intensive care resources available. 7.3 During the first wave of the pandemic, modelling suggested that demand for critical care in Wales could exceed available capacity, even with extra arrangements in place. This helped inform the introduction of non‑pharmaceutical interventions such as social distancing measures to reduce transmission, hospital admissions and pressure on critical care services. As these interventions proved to be effective, demand reduced and later modelling suggested that intensive care services were unlikely to become saturated. Work which had begun to guide the allocation of critical care resources for the most extreme circumstances was paused. Experience over later waves of the pandemic reinforced this position, demonstrating that national interventions could effectively control transmission while health boards increased critical care capacity.

7.4 In 2023, the All‑Wales Critical Care Escalation Guidance was updated to reflect learning from the pandemic. The updated guidance aims to avoid the need for triage by resource. This refers to the allocation or withholding of critical care treatment primarily because of shortages of beds, staffing, equipment or other healthcare resources, rather than according to a patient’s clinical need or expected benefit from treatment. The updated All‑Wales Critical Care Escalation Guidance seeks to avoid the need for such resource‑based triage by strengthening escalation processes, mutual aid arrangements and surge capacity, enabling patients to continue to be prioritised based on clinical need wherever possible. It also includes a clearer definition of critical care pressure levels, known as ‘CRITCON’. 7.5 The Welsh Government alongside NHS in Wales advisers are committed to working at a UK‑wide level to develop a framework for the prioritisation of critical care resources in the extreme event of the service becoming saturated. 7.6 This work will improve clarity, consistency and preparedness for the most extreme situations. The focus will remain on preventing services from becoming saturated through effective planning, early escalation and services supporting each other when under pressure.

The Scottish Government accepts this recommendation in principle and is now working with the other three UK nations to agree a plan to meet this recommendation. This will involve developing an ethical framework of principles that will help guide clinical decision making in intensive care in extreme circumstances beyond usual ‘surge’ levels. It is important to note that this is intended to be used only as a last resort, and that the actions under Recommendations 5 and 6, if effective, should prevent the need for these principles to be put into practice.

We are clear that these principles should be founded in the basis of ensuring as much as possible the welfare of those affected by decisions as well as the welfare of those making them.

The Scottish Government believes a four nations approach will promote transparency, understanding (for patients, their families and staff), accountability and consistency, recognising the different NHS systems in operation across the four nations of the UK.

As discussed with CIREG, the intention is that this process would include wide stakeholder engagement, including human rights organisations and workforce and patient representatives.

The government will explore developing a recognised set of principles to be applied when considering the allocation of adult intensive care resources in the extreme event that they are saturated during a pandemic.

However, as there are complex and nuanced policy considerations, it will take the government longer than 6 months to develop a plan and timeline for completing this work. We are considering how to approach this work and what would best suit the existing health systems across the UK. We will provide an update in May 2027 through the UK Covid-19 Inquiry implementation dashboard.

No statement on delivery from Department of Health and Social Care has been found in the sources searched. This is separate from the response above.